Welcome To Our Practice Northern Oral Surgery & Implant Center

Main Header

PLEASE READ!

Please remember to select the Complete & Send button at the bottom of the form to submit your form to our office.

Spouse or Other Guarantor Information: (If Different From Above)

1. Name

Relationship / Birth Date

Sex

Male Female

Address

City / State / Zip

Home / Cell Tel.

S.S. #

2. Name

Relationship / Birth Date

Sex

Male Female

Address

City / State / Zip

Home / Cell Tel.

S.S. #

Insurance Information

Do you have dental insurance?

Yes No

Do you have medical insurance?

Yes No

Primary Dental Insurance Company

Policy Holder

Birth Date

Address

City / State / Zip

Sex

M F

Relationship to patient

S.S. # / Tel

Ins. Co Name

I.D. #

Address

City / State / Zip

Tel / Group #

Primary Medical Insurance Company

Policy Holder

Birthdate

Address

City / State / Zip

Sex

M F

Relationship to patient

S.S. # / Tel

Ins. Co. Name

I.D. #

Address

City / State / Zip

Tel / Group #

Secondary Dental Insurance Company

Policy Holder

Birth Date

Address

City / State / Zip

Sex

M F

Relationship to patient

S.S. # / Tel

Ins. Co. Name

I.D. #

Address

City / State / Zip

Tel / Group #

Secondary Medical Insurance Company

Policy Holder

Birth Date

Address

City / State / Zip

Sex

M F

Relationship to patient

S.S. # / Tel

Ins. Co. Name

I.D. #

Address

City / State / Zip

Tel / Group #

Health History

To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the care that you will be receiving.

Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Reason for today's office visit?

Is this visit related to an accident?

Yes No

If Yes, what type of accident?

Automobile

Work Related

Other

If the patient is a minor under 18 years of age, or they cannot legally make their own healthcare decisions, a parent / guardian needs to be present for the evaluation AND surgery.

Who makes healthcare decisions for the patient?

Patient (18 years or older) Parent / Guardian Power of Attorney

Name of legal decision maker if not the patient

Medications

Please list any medications you are currently taking (bring a printed list to your appointment, if necessary OR you can upload it to our office once you submit this form):

Is there a family history of

Cancer

Yes No

Diabetes

Yes No

Heart Disease

Yes No

Anesthesia problems

Yes No

Women Only

Is there a possibility of pregnancy?

Yes No

Expected delivery date?

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding other methods of birth control.

Please list any medication or antibiotic you are allergic to

Please list any other allergies, other than drug allergies

Is there any condition concerning your health that the Doctor should be told about?

Yes No

Verification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

AUTHORIZATION

I authorize my surgeon and his/her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and/or mobile phone concerning my appointments or account.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

I am legally authorized to consent for treatment for the above patient.

Yes

Initials

Click to Sign

Date:-------------

Notice of Privacy Practices Acknowledgement and Authorization Form

3617 West Arrowhead Road, Duluth, MN 55811
3899 Highway 73, Suites 5‐6, Hibbing, MN 55746
503 Belknap Street, WI 54880

I understand that as part of my healthcare, Northern Oral & Maxillofacial Surgeons creates and maintains health records that describe my health history, symptoms, examinations, test results, diagnosis, procedures, treatment, and plans for future care or treatment I may receive. I understand that health information collected and stored will be used for the following:

To support my care and treatment at Northern Oral & Maxillofacial Surgeons
For continued treatment among health professionals who are involved and contribute to my health care
For billing purposes including information regarding my diagnosis, treatment, and services rendered
For insurance claim processing by a third‐party payers for verification of services billed
A tool for routine healthcare operations such as assessing quality improvement and reviewing the competence of healthcare providers

I understand that the Notice of Privacy Practices from Northern Oral & Maxillofacial Surgeons defines more information regarding the use and disclose of my protected health information as well as my rights to my health information.

I acknowledge that Northern Oral & Maxillofacial Surgeons has offered me a copy of their Notice of Privacy Practices. I acknowledge and understand the rights that I have over my protected health information.

I authorize the use and disclosure of my protected health information as specified in the Notice of Privacy Practices, including for purposes of treatment, payment, and healthcare operations by Northern Oral & Maxillofacial Surgeons. This can include use and disclosure of my information for continuity of care purposes, payment for services rendered and internal operational purposes defined by Northern Oral & Maxillofacial Surgeons.

Initial

Click to Sign

Date:-------------

I understand that I can get an electronic copy of the Notice of Privacy Practices at http://www.northernoralsurgeons.com/

Authorizations

Here is a list of additional parties (guardian/parent/spouse) who are able to receive information on my behalf:

Name / Relationship to Patient

Patient’s Signature/Legal Representative Signature

Click to Sign

Date:-------------

If Legal Representative, relationship to Patient (parent/guardian..)

Optional: Please e-mail me a copy of the Notice of Privacy Practices to the following e-mail address:

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Welcome To Our Practice Northern Oral Surgery & Implant Center

Main Header

PLEASE READ!

Demographic Information - Superior

Patient Information

Spouse or Other Guarantor Information: (If Different From Above)

Insurance Information

Insurance Information

Primary Dental Insurance Company

Primary Medical Insurance Company

Secondary Dental Insurance Company

Secondary Medical Insurance Company

Health History

Health History

Have you ever had, or do you currently have...

Are You Now Taking

Medications

Health History (cont.)

Is there a family history of

Women Only

Are you allergic to, or had a reaction to

Please list any medication or antibiotic you are allergic to

Please list any other allergies, other than drug allergies

Verification

Verification

Click to Sign

Click to Sign

Click to Sign

Notice of Privacy Practices

Notice of Privacy Practices Acknowledgement and Authorization Form

Click to Sign

Authorizations

Click to Sign

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Welcome To Our Practice Northern Oral Surgery & Implant Center

Main Header

PLEASE READ!

Demographic Information - Superior

Patient Information

Spouse or Other Guarantor Information: (If Different From Above)

Insurance Information

Insurance Information

Primary Dental Insurance Company

Primary Medical Insurance Company

Secondary Dental Insurance Company

Secondary Medical Insurance Company

Health History

Health History

Have you ever had, or do you currently have...

Are You Now Taking

Medications

Health History (cont.)

Is there a family history of

Women Only

Are you allergic to, or had a reaction to

Please list any medication or antibiotic you are allergic to

Please list any other allergies, other than drug allergies

Verification

Verification

Click to Sign

Click to Sign

Click to Sign

Notice of Privacy Practices

Notice of Privacy Practices Acknowledgement and Authorization Form

Click to Sign

Authorizations

Click to Sign

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